IJRPC 2013, 3(2) Salini et al.

ISSN: 22312781

INTERNATIONAL JOURNAL OF RESEARCH IN PHARMACY AND CHEMISTRY

Available online at www.ijrpc.com Research Article

PREVALENCE, RISK FACTORS, ADHERENCE AND NON

ADHERENCE IN PATIENT WITH CHRONIC KIDNEY
DISEASE: A PROSPECTIVE STUDY
AB. Salini* and CI. Sajeeth
Department of pharmacy practice, Grace College of pharmacy, Kodunthirapully P.O, Palakkad,
Kerala, India.

ABSTRACT
This prospective observational study was attempted to investigate the prevalence, risk factors,
adherence and non adherence in patients with chronic kidney diseases among the people in a
private hospital, Thrissur. The study was carried out in a Nephrology department over a period
of 5 months from October 2012 to March 2013. During the study period, a total of 79
participants ranging from 20 to 85 years were studied. The analysis discovered that 34.18 % of
the patients were hypertensive, 22.78% were diabetic and 56.96% had proteinuria. Based on
Cockcroft-Gault and MDRD equations 75.23% of the participants were detected as having
chronic kidney disease(CKD) and prevalence of CKD is found to be significant by these two
methods (P = 0.009). Adherence to drug therapy was evaluated by the self-report method and
pills count method. Medication non-adherence was lower than 5.06% and adherence was about
70.88%. The association between CKD and its risk factors like proteinuria, diabetes mellitus,
hypertension, obese and overweight, was highly significant. In CKD, patients non-adherence to
medication was found to be increasing with the increase of total number of pills taken per day
and drug administration by third parties. Adherence is more frequent than non-adherence over
the study period.

Keywords: Chronic kidney disease, Drug adherence, prevalence, risk factors.

INTRODUCTION diabetic or suffer from high blood pressure. With

Chronic kidney disease (CKD) is a life-
threatening condition characterized by
progressive and irreversible loss of renal
function. CKD is a precursor to end-stage renal
disease, is associated with increased risk of
morbidity and mortality.10% of the Indian
population suffers from chronic kidney diseases
and this figure is expected to increase 7. Indians
are clearly at a higher risk of developing kidney
diseases because of the surge in the number of
patients suffering from diabetes and high blood
pressure. 60% of the patients suffering from
chronic kidney diseases in India are either
constant lifestyle changes amongst teens and
youngsters is leading to an early onset of kidney
related ailments. Consumption of fast food,
sedentary way of living with little or no exercise
is an important cause for the rise in cases of
diabetes, hypertension, gastrointestinal
and obesity in our country and this in turn has
led to increasing incidence of kidney disease 7.
Minimal physical activity, unhealthy diet,
smoking and drinking are some of the reasons
that are resulting in an increased number of
chronic kidney diseases especially among
8
women in both rural and urban India .

404
IJRPC 2013, 3(2) Salini et al.
The National service framework for renal
services adopted the US National Kidney
Foundation kidney disease outcomes quality
initiative (NKF-KDOQI) classification of CKD.
This classification divides CKD into five stages.
Stages 35 may be defined by glomerular
filtration rate (GFR) alone, whereas stages 1
and 2 also require the presence of persistent
proteinuria, albuminuria or haematuria, or
[10]
structural abnormalities . GFR is calculated
from serum creatinine by Cockcroft-Gault and
MDRD equations. Staging of CKD is based on
glomerular filtration rate.
The participants at the WHO Adherence meeting
in June 2001 concluded that defining adherence
as the extent to which the patient follows
medical instructions. A merged version of the
definitions of Haynes and Rand, adherence is a
persons behavior concerning taking medication,
following a diet, and making changes in lifestyle
in accordance with medical or non-medical
health professional recommendations11.
Non-adherence is considered to be a
multidimensional phenomenon related to
multiple factors, and its occurrence can
adversely impact the course of the disease,
particularly in cases of chronic disease. These
factors are determined by the characteristics of
each disease, patients healthcare system,
socioeconomic factors, treatment
characteristics, and the health team who assists
the patient; thus, considering patients as solely
responsible for following treatment is misleading,
mainly because some factors are independent of
their will, particularly the occurrence of different
levels of cognitive decline, treatment of
asymptomatic diseases, medication side effects,
no clarification about the disease, and
medication cost. The methods used to assess
adherence to drug therapy can be classified into
2
direct and indirect .
Directly observed therapy, measurement of
concentrations of a drug or its metabolite in
blood or urine, and detection or measurement in
blood of a biologic marker added to the drug
formulation are examples of direct methods of
measures of adherence 9. Indirect methods of
measurement of adherence include asking the
patient about how easy it is for him or her to take
prescribed medication, assessing clinical
response, performing pill counts, ascertaining
rates of refilling prescriptions and collecting
9 Ccr (mL/ min)=
patient questionnaires .
Most of the studies on kidney disease are
carried out only on the prevalence and risk
factors or adherence to drug therapy. The aim of
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ISSN: 22312781
the present study was to evaluate the
prevalence, risk factors, adherence and non
adherence in patient with chronic kidney
disease.
MATERIALS AND METHODS
The study was carried out in a Nephrology
department over a period of 5 months from
October 2012 to March 2013. A total of 79
participants ranging from 20 to 85 years had
been studied. A total of 105 patients 79 patients
are chosen from that 30 were females and 49
were males.
Inclusion criteria
Patients age between 20 and 85 years
irrespective of sex.
Patient diagnosed with chronic kidney diseases.
Exclusion criteria
Patients who have acute kidney disease.
Patients who did not cooperate with study.
Various variable such as age, sex, marital
status, occupation, family income, literary status,
body weight (in kilogram), height (in centimeter),
and body mass index (BMI) = weight in kg/height
2
in m Risk factors studied were diabetes
mellitus, hypertension, overweight and obesity,
and proteinuria detected by multistick.
According to WHO criteria of Body mass index
(BMI) patient were categorized into normal (BMI
18.524.9), underweight (<18.5), overweight
(25.029.9), obese (30.039.9), and morbid
obese (40.00).
We identified various coexisting illness using
patient medication chart, laboratory results, self
report method and patient direct interview.
Patients have diabetes mellitus if previously they
had been recognized by the doctor as having
DM or any documents in favors of DM or they
reported taking insulin or oral antidiabetic drug
or random plasma glucose 150 mg/dl with
symptom. Hypertension was defined as systolic
BP 140mmHg or diastolic BP 90mmHg or
use of medication for hypertension irrespective
of the blood pressure.
Serum creatinine level is used to estimate the
GFR (glomerular filtration rate) by using
Cockcroft-Gault and MDRD (modification of diet
in renal disease) equations.
1. Cockcroft-Gault equation (1976)
(140-age) Weight (Kg)
0.85 if female
72 S. creatinine (mg/dL)
2. Original MDRD equations (2000)
GFR =186.3 (S. creatinine) 1.154 (age) 0.203 0.742 (if female).
IJRPC 2013, 3(2)
CKD staging was done according to K/DOQI
guideline 2002. Stage 1 includes GFR 90
mL/min, Stage 2 includes GFR 6089 mL/min,
Stage 3 includes GFR 3059 mL/min, Stage 4
includes GFR 15 29 mL/min and Stage 5
includes GFR < 15 mL/min.
Adherence to drug therapy was assessed by the
self-report method which consisted of the
patients information about which drugs he had
taken since the last follow-up visit. Patients older
than 60 years underwent the Minimental State
Examination (MMSE) and, when they were
found to have impaired the caregiver was invited
to answer the questionnaire in the place of the
patient.
Data were collected using structured
questionnaire and patient case record was
finalized after field testing. Software GraphPad
Instat had been used for data processing and
analysis. Test statistics used to analyze the data
were Chi-square test. P values less than 0.05
were considered significant.
RESULTS
Analysis showed that the 62.03% patients were
male and 37.97% patients were females.
51.89% of the patients were middle aged (from
40-59 years of age) while the mean age was
50.11(15.45) years. The majority of the patients
were married 83.54%. Most of the patients
86.07% were non vegetarian, 13.92% were
vegetarian 16.46% were alcoholic and 22.78%
were smoker (Figure 1). BMI study categorized
30.37%of the patients as normal, 31.64% as
underweight, 18.98% as overweight, 17.72% as
obese and 1.26% as morbidly obese. Out of 79
patients 34.18% were hypertensive, 22.78%
were diabetics, 5.06% were dyslipidemia and
21.52 % of patients had combination of
hypertension and diabetes (Figure 2).
Urine albumin analysis using multisticks
demonstrated that 56.96 % of patients had
proteinuria, of them 16.46% had+ proteinuria,
17.6 % had ++, 20.25 % had +++proteinuria
and 2.53% had ++++ proteinuria.
The mean eGFR by Cockcroft-Gault equation
was 26.63mL/minute in males and 35.42
mL/minute in females, while the mean eGFR by
MDRD equation was 24.84 mL/ minute in males
and 32.09 mL/minute in females.
Stage 5 chronic kidney disease was most
dominant 45.57% in Cockcroft-Gault equation
and 46.83% in MDRD equation (Table 2) and
the prevalence of CKD is found to be significant
by these two methods (P = 0.009).
Salini et al. ISSN: 22312781
Most patients self administered their own
medication 83.54% and the average daily
number of tablet 7.7 1 were 15.15% were non
adherent and 84.85% were adherent.
Middle aged and elderly (from age 40 to 59
years) patients tends to develop CKD more than
the young and early middle aged patients. The
risk factors are significantly associated with
hypertension, diabetes, proteinuria, food habit
and smoking.
DISCUSSION
The present study conducted for detection of
chronic kidney disease and its associated risk
factors and patient medication adherence to the
treatment. The prevalence study was done to
examine the prevalence of diabetes mellitus,
hypertension, and chronic kidney disease
(based on proteinuria and low GFR) and to find
the association of CKD with sociodemographic
and other alleged risk factors. Non-adherence to
medication in chronic illness significantly
increases morbidity and mortality, especially in
developing countries. The measurement of non-
adherence and the risk factors associated with it
aim to develop interventions to improve
adherence. Non-adherence to drug therapy has
2
multifactorial origins .
Most studies on adherence to drug therapy in
renal diseases are conducted on post-transplant
patients and evaluate the percentage of non-
adherence to immunosuppressants and
outcomes such as death and graft loss. So far,
only few studies have been published on the
evaluation of adherence by patients with kidney
disease not yet on dialysis, a fact that justifies
the relevance of the present study2. Our study
mainly focused for the prevalence and risk
factors for chronic kidney disease and also
these patients have long term medication to
control the risk factors such as diabetes and
hypertension so the adherence to the
medication was very poor in these patients.
In the case of adherence there is no satisfactory
gold standard method for assessing adherence
to drug therapy, since all methods have
limitations related to low sensitivity and
specificity2. We used the self-reported method to
test patients adherence, which was applied
during the patient admitted in the hospital. Since
this method is easy to use and interpret, it can
be incorporated into the management of patients
with kidney disease.
Comparisons of results from this study with
previously published reports are difficult due to
the great diversity of methods used in assessing
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IJRPC 2013, 3(2)
adherence and the scarcity of publications on
patients with clinical conditions similar to those
of our patients.
In the present study we found that 62.03% were
male and 37.97 % were female patients.
Prevalence of CKD more in middle aged and
elderly (from age 40 to 59 years) patients of
about 51.89%. Prevalence of CKD in the mean
age was 50.11(15.45). The previous studies
such as Prevalence of CKD in the slum areas of
Mirpur in Dhaka city of Bangaldesh showed that
the 55% of the participants were young and
early middle aged (from 15-40 years of age)
while the mean age was 34.39 (12.70) years1.
Prevalence of CKD in Kinshasa showed that
58.1% of the participants were in the age range
between 20 and 39 while the mean age was
38.6 14.43.
We found 22.78% of the patients were diabetes,
34.18% were hypertensive, 5.06% had
dyslipidimia, 21.52% had combination of DM
and HTN, 1.26% had combination DM, HTN and
dyslipidimia, 2.53% had combination of HTN and
dyslipidimia and 6.33% had renal disease in our
study. The previous population based studies
had examined the prevalence of hypertension
12
was 38.8% and diabetes 2.9% respectively .
Urine albumin analysis using multisticks found
that 56.96% of the patient had proteinuria. The
previous study had examined the prevalence of
proteinuria detected by dipstick result of 7.7% of
the participants had proteinuria 1.
Prevalence of CKD categorized based on
MDRD equation was 46.83% of patients had
stage 5 CKD. The mean eGFR in male was
found to be 24.84 mL/ minute and 32.09 mL/
minute in female. Prevalence of CKD
categorized based on Cockcroft-Gault equation
was 45.57% of patients had stage 5CKD. The
mean eGFR in male was found to be 26.63 mL/
minute and 35.42 mL/ minute. The previous
study found that the mean eGFR by Cockcroft-
Gault equation was 85.1mL/minute in males
and 99.2mL/minute in females, while the mean
eGFR by MDRD equation was 100.8mL/minute
1
in males and 133mL/minute in females .
Salini et al. ISSN: 22312781
Based on Cockcroft-Gault and MDRD equations
75.23% of the participants were detected as
having chronic kidney disease(CKD) and
prevalence of CKD is found to be significant by
these two methods (P = 0.009). Md Nurul Huda
et.al studies 13.1% were identified as CKD by
MDRD equation and 16% by Cockcroft- Gault
equation. The prevalence of CKD did not differ
1
significantly between the two methods .
Association of demographic factor with CKD
showed that age >40 years was significantly
prone to developing CKD compared to age <40
years. The earlier study show that the middle-
aged and elderly (from 41 to 65 years)
population tend to develop CKD more than the
young and early middle-aged population (from
1
15 to 40 years of age) .
In this study, diabetes mellitus and hypertension
were present in significant proportions in CKD
group compared to combined prevalence of DM,
HTN, and proteinuria.
Comparisons of results from this study with
previously published reports are difficult due to
the great diversity of methods used in assessing
adherence and the scarcity of publications on
patients with clinical conditions similar to those
of our patients. The present study most patients
self administered their own medication
83.54% and the average daily number of tablet
7.7 1 were 15.15% were non adherent and
84.85% were adherent. The previous study
observed that the number of non-adherent
patients increased throughout the study (up to
26.8%), but it is worth noting that the percentage
of adherent patients who became non-adherent
(22%) was lower than the percentage of non-
adherent patients who became adherent (50%),
possibly demonstrating the educational role of
the interdisciplinary team in monitoring patients
with CKD2.
This study had limitations at baseline the
interview to evaluate adherence to drug therapy
was assessed by the self-report method. To
improve the adherence to drug therapy another
method such as interventional method is used
which is more useful to compare the adherence
drug therapy.
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IJRPC 2013, 3(2) Salini et al. ISSN: 22312781

Table 1: Characteristics of study population

Clinical features No of patients = 79 %
Gender
Male 49 62.03
Female 30 37.97
Age (mean SD) (years) 50.1115.45
Age range (years) 20- 85
20-39 (years) 18 22.78
40-59 (years) 41 51.89

60-79(years) 17 21.52

80 (years) 3 3.79

History of hypertension 18 22.78

History of diabetes 27 34.18

History of proteinuria 45 56.96
History of renal disease 5 6.33
History of over wt and obese 29 36.70
History of smoking 18 22.78
History of alcohol use 13 16.46

Table 2: Prevalence of CKD

2
Stages of CKD MDRD (ml/min/1.73m ) Cockcroft- Gault (ml/min)
No of patients % No of patients %
Stage 1 90 ml/min 2 2.5 4 5.06
Stage 2 60-89 ml/min 9 11.39 7 8.86
Stage 3 30-59 15 18.98 13 16.46
Stage 4 15-29 16 20.25 19 24.05
Stage 4 < 15 37 46.83 36 45.57

100
83.54 86.06

80
62.03
60
%

37.97
40 34.18
22.78
16.46
20

Sociodemographic characteristics
Fig. 1: Dominant sociodemographic characteristic of the patients

408
IJRPC 2013, 3(2)
60
50
34.18
40
30 22.78
%
20
10
0
Fig. 2: Distribution of patients by risk factors: The commonest risk factors
CONCLUSION
The present study revealed that CKD is present
more in the age group between 40 to 59 years of
age. The commonest risk factors for CKD like
DM and hypertension are also alarmingly high
and obviously adding to the existing burden of
CKD. The association between CKD and other
risk factors like age, obese and overweight, use
of tobacco, DM, and HTN was also highly
significant. When more than one risk factor was
present, the chance of developing CKD was
extensively eminent. The adherence to drug
medication was identified most patients self
administered their own medication 83.54% and
the average daily number of tablet 7.7 1 were
15.15% were non adherent and 84.85% were
adherent.
ACKNOWLEDGMENTS
The authors are thankful to the Principal,
Librarian Grace College of pharmacy for
providing e search facilities and journal for
review of literature. This study was supported by
grant Dr. T.T. Paul. MD. Consultant Nephrologist
from West fort hospital, Thrissur.
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